A cautionary tale for keeping dental records

All clinicians know the importance of dental records. Many write extremely comprehensive notes, whilst others rely very heavily on auto-notes and auto templates. These can be helpful but can also lead to inconsistencies.

When extracting a lower molar, a warning relating to an oro-antral fistula is unlikely to convince a claimant’s lawyer that any other warnings in the records have credibility. It can lead to doubt as to whether any warning was even given.

Wake-up call

Sometimes it isn’t the volume of record which matters but the small things that justify an action. In a recent claim, a patient had suffered from sinusitis, pain, and suffering following displacement of the palatal root of an upper first molar tooth into the sinus.

The records revealed that the patient had attended the practice via an emergency dental service referral. They were not a regular patient. The dentist explained verbally that the roots of the tooth were close to the antrum but that, based on past experience, referral to the local oral surgery department would result in the referral being rejected with the advice that treatment should be provided in practice. They were confident in their own skills to complete the extraction.

Unfortunately, this discussion was not recorded and of course represented a significant failure. The dentist acted appropriately after the incident and referred the patient immediately with a referral marked ‘urgent’. An appointment was made within three months but the patient failed to attend.

The patient subsequently suffered pain and discomfort and ultimately needed the root to be retrieved. The dentist was criticised for not following up the missed appointment (of which the dentist was notified) with the patient.

Defence case

In defence, Royal Sun Alliance, following detailed advice from the Densura dentolegal adviser, made the case that indeed a verbal warning had been given but there was little merit in offering a referral for extraction as this would have been rejected. Furthermore the patient had a responsibility to attend the appointment arranged.

It was not for the dentist to re-refer given that the patient was no longer under their care. The case was made that much of the pain and suffering alluded to, stemmed from the failure of the patient to attend the appointment arranged. Had the patient done so, they would not have suffered in this way.

The initial claim for £5,000 could not be completely defended because of the lack of written record but was negotiated to £2,500. Overall however, this case cost over £21,000 due to the legal fees involved.

This may seem like an unjustified claim, but, given the lack of written evidence of warning and options being given, was one that was best settled when the opportunity to negotiate arose.

A lesson learned

The take away message from this is to record negative actions as well as positive. A brief note along the lines of: ‘Option to refer for extraction discussed – patient advised this would likely be rejected. Warned of proximity of tooth roots to antrum – patient in pain and wanted extraction – agreed to proceed but advised could be complications due to sinus but would manage if required’, would have made a significant difference. It would’ve possibly prevented any claim being lodged in the first place.

As always it is easy to be wise after the event. In my experience the best note keeper is often your dental nurse who can write down these conversations and warnings in real time.

In this situation it would have been invaluable, even though the dentist did everything possible to help the patient. Clinically it is difficult to be critical of the care they provided.